Laserfiche WebLink
TANK CLOSURE CERTIFICATION FORM <br />?" — of — <br />I <br />EACH my inENTIFICATION <br />BUSINESS NAME <br />3 FACIIJTY ID s 1 <br />SITE ADDRESS <br />104 <br />BUSINESS CITY <br />105 <br />BUSINESS LP 108 <br />TANK DINNER NAME <br />500 <br />TANK CWNER ADDRESS <br />501 <br />TANK OWNER CITY <br />502 <br />STATE 503 I AP 504 <br />RF 1NFQRMAT1QN <br />Tank;* <br />(State Tank IDit, if applicable) <br />Flammable Vapor Oxygen <br />Top Center Bottom Top <br />Canter <br />Bottom <br />Tank Interior <br />Atmosphere <br />Readings <br />CERTIFIER TITLE 507 <br />) <br />Name of CUPA/UA <br />If certifier is other than CUPAILIA check appropriate box below: <br />❑ Certified Industrial Hygienist (CIH) <br />❑ Certified Safety Professional (CSP) <br />ADDRESS <br />CITY <br />PHONE <br />DATE CERTIFIED soa <br />CERTIFICATION TIME <br />❑ Certified Marine Chemist (CMC) <br />❑ Registered Environmental Health Specialist (RENS) <br />❑ Professional Engineer (PE) <br />f <br />❑ C1ass It Registered Environmental Assessor <br />❑ CSLB licensed contractor (with hazardous substance certificate) <br />III CERTIFICATION <br />On examination of the tank. I certify the tank is visually free from product. sludge. scale (thin, flaky residual of tank contents), rinseate and debns_ I further certify <br />that the information provided herein is true and accurate to the best of my knowledge. <br />CERTIFIER SIGNATURE <br />STATUS OR AFFILIATION OF CERTIFYING PSRSCN 505 <br />Certifier is a representative of the CUPA/LIA: YES ❑ NO ❑ <br />CERTIFIER NAME (PRINT) 505 <br />CERTIFIER TITLE 507 <br />Name of CUPA/UA <br />If certifier is other than CUPAILIA check appropriate box below: <br />❑ Certified Industrial Hygienist (CIH) <br />❑ Certified Safety Professional (CSP) <br />ADDRESS <br />CITY <br />PHONE <br />DATE CERTIFIED soa <br />CERTIFICATION TIME <br />❑ Certified Marine Chemist (CMC) <br />❑ Registered Environmental Health Specialist (RENS) <br />❑ Professional Engineer (PE) <br />❑ C1ass It Registered Environmental Assessor <br />❑ CSLB licensed contractor (with hazardous substance certificate) <br />❑This tank previously held flammable or combustible materials. If yes. the lank interior atmosphere shall be re -checked with a combustible gas <br />Yes El No <br />indicator prior to work being conducted on the tank. <br />Certifier's tank management instructions for scrap dealer, disposal facility, etc: <br />A copy of this certificate shall accompany the tank to the recyding/disposal facility. <br />